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Dental Implants – Teeth with Titanium P6

Another younger patient with what’s a sarcoma or a tumor of the bone end up with implants and a graft.  Removable, again, because in this case, you can see where these teeth are and how far down this bone is.  So, we needed to replace normally the teeth with the gum to make it look normal, and therefore, a larger prosthesis to make the gum functional again.

Lower jaw in the front, a large cancer that was removed.  Rebuilt with bone from the leg, and at the same time, implants placed in that jawbone.  After healing and radiation therapy and a bar, the denture that made this patient functional again.

This technology of osseointegration has moved on from teeth to other parts of the body.  Our application is to the head and face.  It’s very interesting when I see patients for making ears and noses and eyes.  They always wonder why they’re seeing a dentist, but it’s because the process of how it’s made is very similar to teeth.  We can use implants that are smaller in size that help hold the ear.

This patient had a melanoma.  Lost part of the ear.  We make him a traditional ear prosthesis out of silicone.  Has to be glued to place.  Not very stable.  Not very functional.  We can place some implants and have a bar, and then when we have an ear, there’s a magnet and a clip that actually helps hold that in place.  You can see what that restoration looks like from this patient.

This is a lady who had her nose removed from a cancer.  Implants were placed in the upper part of the jaw, implants and a bar that were made, and then a nasal prosthesis that restored this patient back to normal.

So, the technology and how it’s used in treating these patients is pretty amazing in what we are able to do for them.  An eye prosthesis for somebody.  Now, again, you got to remember, these prosthesis are not functional like teeth.  It’s for cosmesis, making them acceptable in society, making them comfortable, psychologically, to go out in public so they feel closer to normal.

I tell patients with the eye that all I’m doing is making you a custom eyepatch.  You don’t have a piece of white gauze and black patch that you’re wearing.  You’ve got something that looks more normal so when you’re walking down the street, people shouldn’t take a second look and try to figure out what’s going on with you.

This is the largest on that I’ve ever made.  This is a large facial cancer on a patient that we were able to place implants, and give him a prosthesis.  It made him halfway presentable, still not ideal but presentable.

Now, we got to talk about failures in the last three minutes or so here.  Failures can be broken down into multiple categories.  The first one is biological.  So we’ve got an implant here.  You can see the threads, and there’s blood on it because this was put in bone and it didn’t take.  For some reason, the bone did not grow into the surface of the titanium.  We call it a biologic failure because the biology didn’t work here.  Why did it not work? Well, it could be because the surface may have been contaminated.  It could be because the surgeon didn’t do the surgery in an atraumatic manner so the bone was drilled too fast.  Maybe the bone didn’t have the capacity to heal.  We do have scenarios where the bone has poor blood supply, poor vascularity, inability to heal normally.

We look at biological failure.  We break it down into two categories.  One is early that you put the implant in. You wait the three months.  You go back to put the second piece on, and you find that the implant is loose.  It never took.  That’s an early failure.  We call a late failure after loading.  That means it took.  I made a tooth that I put on there.  You started to chew on that tooth.  In a couple of months, it fell out.  So really, the bone grew into the surface of the implant.  That inferface between the bone and the implant was not strong enough to withstand the forces of chewing that you were putting on that tooth.  So, those are both biological failures.

We also have something that we call a mechanical failure, and we are starting to see more of these now because we’ve had these implants in our patients 15, 20 years.  Basically, mechanical failure is fatigue.  You take anything in metal, and you bend it.  You flex it. You flex it and flex it.  There’s going to a come a point in time when it can break.  It’s the paperclip right?  You bend it.  You bend it.  You bend it. You bend it, and boom it goes.  So, we are looking at this seriously.

It may be the dimension of that implant that we had made, and most of these kind of mechanical failures occur in the one tooth situation because when you saw multiple teeth, one of the things I didn’t point out was when you make multiple teeth, they’re all connected together.  The idea of connecting them together is that the force or the stress is shared between the multiple implants.  All the load is not just going to one implant.

People will say, “Well you’re putting so many implants, why are you connecting them?  I can’t really floss in here anymore”.  Well, it is a little bit more difficult for you to floss, but the biomechanical advantage is significant.  Therefore, we want to connect them together.  In the single tooth situation, we don’t have the ability to do that, and that’s where we see most of our failures.

So, we’re talking about maybe having a fatter screw that’s thicker, maybe talking about modifying the bites so there’s not a load placed on that, modifying the strength of the implant.  Most of the implants are made with what’s called commercially-pure titanium or 99.9% titanium.  Titanium is a pretty soft allow.  So, the idea is can you alloy this titanium to be able to make it stronger?  There are companies working on that to see can we mix something in there that will make it a stronger alloy but not interfere with the property of the bone growing out of the surface.

So, this is the one that’s fractured as you can see.   When it fractures, what do you do?  It’s actually a problem in a way because if it’s broken like this one here, it’s not easy to take out because the bone is still growing out of the surface of this thing.  The only way you can get this implant out is to core it out.  You’re going to have to get what we call a trephine or an apple core that’s going to go completely around this implant, and you run the risk of a lot of damage to adjacent structures.

In this particular patient that was broken, we opted to just leave it in there.  It was not going to do any harm.  It was buried and he ended up getting a traditional bridge because his tooth, the next one, already had a crown on it.

Biological failures are also related to the inability to clean.  So, this patient, as you see, he’s not doing a good job.  You see a lot of buildup of tartar and calculus.  They’re not doing a good job of cleaning them.  What’s that going to do?  It’s going to harbor bacteria.  The bacteria that’s going to be there is going to create inflammation.  You can see the irritation and swelling, and if that goes on long term, there’s going to be pus.  It’s going to cost a problem.  So, maintaining these implants is a critical part of it. You just can’t say, “I’m going to have the implants placed in my mouth, and then, I’m done.  I’m never going to see the dentist again.”  You are stuck, too.

I tell my patients almost-always that they’re married to me.  They can’t go any place.  They have to come back.  There’s going to be maintenance.  There’s going to be issues, and with that are costs associated with it.  So, you have to be prepared for that.

You can see how much tartar and calculus can build up because what happens for a lot of these patients, they’ve been wearing dentures for 10, 15 years.  They don’t own a toothbrush, and all of a sudden we tell them, “You have to start brushing your teeth again.”  They haven’t done it for so long.  It’s not easy.  Some of them are older.  Their vision is not so good.  The manual dexterity is not so good.

It’s a challenge for us which when we first started doing this, we didn’t pay enough attention to.  We didn’t really realize that.  We are very proactive now.  We don’t let these people get away or start off on a bad track.  If we feel someone can’t do good oral hygiene, we sometimes don’t make them bridges.  We make them the dentures that they could remove from their mouth and clean because they’re less complex, and they’re easier to clean outside the mouth than having something screwed into the mouth like you see here.

You see a lot of buildup of tissue or tartar and what the tissue’s doing to it.  In the single bar, it’s all tartar.  You have to see your hygienist to have your teeth cleaned every three to four months.   In fact, the way tartar sticks to this titanium, it’s very tenacious.  Hygienists have to work really hard to get it off.  It doesn’t come off as easily as it does with natural teeth.

We give our patients a whole box of tools that they’re going to need to keep this clean.  It’s not just about having a toothbrush anymore.  You spend a lot of time and a lot of money, a big investment, in it, and you’ve got to take care of it.  You have mirrors and things that allow you to floss and keep that clean.

These are all the stuff I give my patients when they finish an implant.  So, they walk away with a goodie bag.  It’s like going to a kid’s birthday party and going with a present and leaving with one.  So, they leave with all these stuff.

In the dental school, we actually think titanium is pretty incredible, and we’re hoping the Golden Gate Bridge will refurbish itself with titanium so it won’t rot.  Maybe our tolls won’t go up the way they’re going up right now.  The maintenance would be less of a problem.

So, open for questions.  Who wants to start?  Right over here, sir.

I’m not sure I get your question.  Your question is that because an implant doesn’t have the ligament, you have a natural tooth next to it that’s a ligament, is that going to fail?  Well, interestingly not because it doesn’t have a shock absorber.  It doesn’t have that path for bacteria to go down as easily.  Therefore, you don’t get the same kind of periodontal disease or the recession that you get in natural teeth.  You also don’t get cavities because titanium can’t get decay.

So, there are certain advantages.  We still don’t think that titanium’s that good that you should take out everybody’s teeth and put titanium in it, instead.  It’s not 100% successful yet, but, no. there isn’t a higher risk of failure.  The failure mechanism of titanium implants is not the same as it is for teeth.  The failures that occur in teeth are ligament-related which are not there.  We don’t have it.

The failures here typically are if an implant has been in a person’s mouth long term, biological failure is not going to occur.  Biological failure has two types:  failure that occurs because the bone didn’t grow into the surface or after you load it in the first few months, that interface is not strong enough to tolerate that loading, and it’s going to be lost.  If you go pass the one earmark, the failure of implants is very low.  It’s like 0.2%, 0.3%, but it’s only been 15, 17 years.  I can’t tell you what’s going to happen 50 years from now.  We haven’t followed them long enough.  There are probably going to be other failures like the mechanical failure that I showed you, potentially.

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